对2021年美国肝病学会腹水和肝肾综合征的诊断、评估和管理指南的质疑与临床实践

Questioning and clinical practice of the 2021 American Association for the Study of Liver Disease: guidelines for the diagnosis, evaluation and management of ascites and hepatorenal syndrome

2021年5月3日美国肝病学会在线发布了关于腹水和肝肾综合征的诊断、评估和管理指南。反复阅读、思考后认为推荐意见中部分条款缺乏辨证思维理念,发病原因、发病机制、诊断与治疗间存在较多矛盾现象,其中包括:(1)保持"负钠平衡"是否诱发周围循环功能障碍及肝肾综合征(hepatorenal syndrome, HRS);(2)钠潴留机制亢进和尿钠排泄减少是否可作为限钠治疗依据;(3)为什么使用超常剂量醛固酮拮抗剂和呋塞米不能抑制其活性和应对钠潴留问题;(4)人白蛋白治疗肌肉痉挛是否有理论依据;(5)利尿剂耐药是否与低钠血症有关;(6)肝硬化和腹水管理复杂性是否与持续限钠有关;(7)HRS与急性肾损伤相提并论利弊关系;(8)使用超常剂量人白蛋白是否能缓解HRS病理生理过程;(9)缩血管药出现抵抗或无应答原因。

On May 3 rd, 2021, the American Association for the Study of Liver Disease(AASLD) published the guidelines for the diagnosis, evaluation and management of ascites and hepatorenal syndrome online. After repeated reading and thinking, it is considered that some terms in the recommendation lack the concept of dialectical thinking, and there are many contradictions among pathogenesis, diagnosis and treatment, including:(1) whether maintaining "negative sodium balance" induces peripheral circulation dysfunction and hepatorenal syndrome(HRS);(2) whether the hyperventilation mechanism of sodium retention and the reduction of urinary sodium excretion can be used as the basis for sodium treatment;(3) what is the reason why using the ultra dose aldosterone antagonist and furosemide can not inhibit its activity and sodium retention;(4) whether there is a theoretical basis for the treatment of muscle spasm with human albumin;(5) whether diuretic resistance is related to hyponatremia;(6) whether the complexity of liver cirrhosis and ascites management is related to continuous sodium restriction;(7) HRS is compared with acute renal injury;(8) whether the use of supernormal dose human albumin can alleviate the pathophysiological process of HRS;(9) causes of resistance or no response to vasoconstrictors.